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Download Cytogenetics Request Form - 49.62kb PDF
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PATENT NO. 2221208 B PATIENT’S SURNAME CYTOGENETICS, INSTITUTE OF GENETIC MEDICINE REQUEST FOR CENTRAL PARKWAY, NEWCASTLE UPON TYNE NE1 3BZ CHROMOSOME ANALYSIS TEL 0191 241 8700 FAX 0191 241 8713 D.O.B. SAMPLE TYPE ............................................................................... SEE OVER FOR INSTRUCTIONS FORENAME(S) M / F CLINICAL DETAILS AND REASON FOR REFERRAL PATIENT’S ADDRESS POSTCODE HOSPITALWARD HOSPITAL No. NHS No. CONSULTANT REPORT TO G.P. / PRACTICE DELETE AS NECESSARY NHS / PRIVATE IF AGED UNDER 16 PLEASE GIVE MOTHER’S NAME NHS No. FOR LABORATORY USE D.O.B. Samples will be processed only if full information is given In submitting this sample, the clinician confirms that consent for the investigations requested has been obtained. Date of Specimen ............................ Time Taken ......................... JB-24462 CYTOGENETICS IF LABEL USED APPLY BELOW Signature ....................................................................................... Print Name ..................................................................................... Contact No. ................................................................................... LABORATORY NOTES Skin, Fetuses, Fetal Material and Products of Conception Blood Samples CYTOGENETICS For all URGENT referrals, such as newborn babies, please send a minimum of 2ml blood in LITHIUM HEPARIN and 1ml blood in EDTA. 0191 241 8702 PLEASE DO NOT USE TUBES WITH A CAPACITY OF LESS THAN 2ml Amniotic Fluid Samples 10-20ml in a sterile plastic universal bottle, to arrive the same or next day. Store at room temperature if kept overnight. Details of LMP, scan and any relevant obstetric history should be given. Inform laboratory when specimens are sent. 0191 241 8795 Fetuses requiring post mortem will be forwarded to Pathology at the Royal Victoria Infirmary, Newcastle, unless alternative instructions are received. Fetuses not requiring a post mortem will be returned to the referring hospital. ER/POC will be cremated by the RVI unless alternative instructions are received. 0191 241 8796 User Manual Copies of the user manual may be requested by telephone: 0191 241 8700 or downloaded from http://www.newcastle-hospitals.org.uk/ services/northern-genetics.aspx Chorionic Villi In transport medium provided, to arrive at the laboratory without delay. Details of LMP, scan and relevant obstetric history should be given. Inform laboratory when samples are sent. 0191 241 8795 Bone Marrow Please send in tubes of culture medium (provided by Cytogenetics), without delay. Please ensure same day receipt in laboratory. Inform laboratory when samples are sent. 0191 241 8703 Solid Tumours By arrangement only. 0191 241 8703 CYTOGENETICS, INSTITUTE OF GENETIC MEDICINE CENTRAL PARKWAY, NEWCASTLE UPON TYNE NE1 3BZ TEL 0191 241 8700 FAX 0191 241 8713 CYTOGENETICS For array CGH in patients with e.g. developmental delay and/or dysmorphic features, please send at least 2ml blood in EDTA. Array CGH will identify copy number changes at a higher resolution than G-banding. Array CGH will NOT detect balanced rearrangements and has limited sensitivity for the detection of mosaicism. IT IS IMPORTANT THAT THE CORRECT SPECIMENS ARE SENT. PLEASE CONSULT YOUR PROTOCOLS OR CONTACT CYTOGENETICS IF YOU ARE UNSURE. Send smaller samples in sterile saline. Send fetuses and large specimens in a clean, sterile container. If possible, send the same day. Otherwise, store at 4˚C overnight. Include the placenta with any fetus. DO NOT ADD FIXATIVE. DO NOT FREEZE. Give gestation and details of relevant obstetric history. PLACE SPECIMEN CONTAINER IN BAG AND PLACE BAG ON FLAT SURFACE. REMOVE PROTECTIVE STRIP, FOLD ONTO BAG AND SEAL FIRMLY For G-banding in patients with possible trisomies (including Down syndrome), sex chromosome investigations or infertility, please send 5ml venous blood in a LITHIUM HEPARIN tube to arrive the same or next day.
